National Initiative Strives to Reduce Surgical Site Infections

September 1, 2004

National Initiative Strives to Reduce Surgical Site Infections

By Kelly M. Pyrek

Perioperative infections complicate an
estimated 2.6 percent of nearly 30 million operations annually, resulting in
approximately 780,000 surgical site infections (SSIs).

Tried-and-true methods of preventing these SSIs with a
particular emphasis on the administration of antimicrobial surgical prophylaxis
are being supported by the work of a number of physicians, nurses and
infectious-disease experts from the entire healthcare continuum. Their efforts
to reduce the 40 percent to 60 percent of preventable SSIs have culminated in
the Surgical Infection Prevention project (SIP), a national quality improvement
initiative launched two years ago and co-sponsored by the Centers for Medicare
& Medicaid Services (CMS) and the Centers for Disease Control and Prevention
(CDC). SIP is conducted through the CMS Health Care Quality Improvement Program,
and its goal is to reduce the occurrence of post-operative infection by
improving the selection and timing of preventive antibiotic administration.

In June, the authors of all current U.S. surgical infection
prevention guidelines, along with professional organizations that are involved
in surgical care, released a joint advisory statement on infection prevention,
Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection
Prevention Project.

This advisory statement is the result of a year-long effort
by leading national medical organizations to identify best practices for
preventing surgical site infections, says Peter Houck, MD, leader of Medicares
National Surgical Infection Prevention Project. We are pleased that this
statement has been accepted by more than 20 medical societies and national
healthcare organizations.

Participating organizations were American Academy of
Orthopaedic Surgeons, American College of Obstetricians and Gynecologists,
American College of Surgeons, American Geriatrics Society, American Society of
Health-System Pharmacists, Infectious Diseases Society of America, The Medical
Letter, Society of Thoracic Surgeons, Surgical Infection Society, Society for
Healthcare Epidemiology of America, and VHA, Inc.

Representatives of these and other organizations serve on the
projects expert panel. The expert panel meets monthly to provide clinical
expertise and support to the CMS/CDC steering committee on project features,
such as operations/procedures, quality indicators, support and collaboration.
The expert panel is comprised of leading infectious disease and surgical experts
representing more than 16 national organizations.

When SIP was launched in 2002, clinical experts identified
areas of inconsistency among the existing surgical infection prevention practice
guidelines, as well as issues that were not addressed in any of the guidelines.
Areas of focus included selection of antibiotics for patients with certain
antibiotic allergies, and the duration of antibiotic therapy after completion of
the operation.

Project leaders hosted a forum of national medical
organizations in January 2003 which led to initial consensus regarding
antibiotic selection, timing, and duration for certain surgeries. The resulting
advisory statement was accepted by all of the participating organizations, as
well as additional national medical organizations. The principle concepts coming
out of this forum were recommendations that antibiotics used to prevent surgical
infection should be given during the hour before surgery and that they should
not be used for more than 24 hours after the end of the operation. Timely
administration results in more effective infection prevention, while short
duration is less likely to produce antibiotic-resistant bacteria, experts

Optimal prophylaxis ensures that adequate concentration of
an appropriate antimicrobial are present in the serum, tissue, and wound during
thee entire time that the incision is open and at risk for bacterial
contamination, Bratzler and Houck1 write. The antimicrobial should be active
against bacteria that are likely to be encountered during the particular type of
operation being performed and should be safe for the patient and economical for
the hospital. The selection and duration of antimicrobial prophylaxis should
have the smallest impact possible on the normal bacterial flora of the patient and the microbiologic ecology of the hospital.

One of the things we identified very early in the process of
developing the SIPP was the fact there were quite a few different guidelines for
antimicrobial prophylaxis, and we wanted to achieve consistency, says Dale
Bratzler, DO, of the Oklahoma Foundation for Medical Quality. To some extent,
our goal was to simplify the guidelines, get the authors of the guidelines
together, and in the process of reviewing the literature and talking about the
guidelines, we might develop some consensus and consistency in the guidelines as
they were updated. That has definitely happened.

Most importantly, SIP addresses the need to translate clinical
research into real-world practice.

I think translating research into practice is a key issue,
Bratzler says. As I travel the U.S. speaking about SIP, I frequently point out
that the original data (suggesting administering the first antimicrobial dose
within the hour before surgical incision) was first published in 1957; it has
taken 40 years to get that evidence into practice. And were still not there.
Its critical to take evidence from clinical trials and then get hospitals and
operative teams to apply it to practice. He continues, Its not easy
work. In our audit, more than 99 percent of the patients got an
antibiotic dose; the doctors almost never forgot to give one, but the timing
was not good. Only about 60 percent of patients got their .rst dose within
an hour before the incision. Its all about empowering someone to make sure
the antibiotic is turned on within that hour before incision. Its not that
people dont understand and recognize theres real benefit from antimicrobial
prophylaxis, but the challenge is putting the system in place to make sure it
happens with every patient.

To that end, a number of hospitals have created regional SIP
collaboratives. One of the most successful has been the Surgical Infection
Prevention Collaborative Northwest (SIP NW) in which 11 Washington state
hospitals have worked for the past year to reduce their SSI rates. The major goals of the SIP NW have been the proper
administration of antibiotics, along with clipping not shaving the
surgical site, and maintenance of proper body temperature before and after

At the 240-bed Overlake Hospital Medical Center in Bellevue,

  • 100 percent of all surgical cases received an
    appropriate selection of antibiotic prophylaxis
  • 75 percent of patients received antibiotics within an
    hour before surgical incision
  • 97 percent of patients who received antibiotics had
    those medicines discontinued within the appropriate 24-hour period after
  • 72 percent of surgical patients had a temperature
    greater than 36 degrees Celsius
  • 88 percent of surgical patients had their hair removed
    at the surgical site without shaving

According to the
summary report for the SIP NW Outcomes Congress, in 2002, Overlake had 12 SSIs,
and in 2003, that number was reduced to five, equating to a cost savings of

At the 142-bed St. Marys Medical Center in Walla Walla,

  • Appropriate antibiotic prophylaxis was administered to
    100 percent of eligible patients in the pilot group
  • The proportion of patients receiving antibiotic
    prophylaxis within one hour before surgical incision was increased from 74
    percent to 100 percent
  • The percentage of surgical patients with antibiotics
    discontinued within 24 hours after surgery went from 70 percent to 92 percent
  • The proportion of patients demonstrating minimal heat
    loss went from 25 percent to 92 percent
  • The proportion of patients undergoing appropriate hair
    removal at the surgical site changed from 10 percent to 80 percent

St. Marys summary report said, Changes in the perception
of acceptable rates of infection have shifted to zero. There are no acceptable
rates of healthcare-associated infections.

As Ive traveled across the country, Ive seen a wide
mix of hospitals participating in these local and regional collaboratives,
Bratzler says.

There is a lot of excitement around the collaborative
process, bringing people together for the common cause of fighting SSIs. In
Oklahoma, we started our collaborative on surgical infection prevention and
marketed it to infection control practitioners (ICPs) and operative teams, not
necessarily the same audience we usually would use for most of our quality
improvement projects. We targeted ICPs because we thought they were very
important in terms of helping the hospitals take action on some of these
performance measures. I think getting ICPs involved is the way its been
across most of the country.

Houck says ICPs passion about the project is contagious.
I spoke at the annual APIC meeting again this year and I was very impressed
with their enthusiasm. A lot of them were already working on SSI-prevention
projects, and many of them were participating in a SIPP collaborative. I thought
there was a terrific amount of energy there. The infection control community
really sees SIP as a way to prevent infections as well as a way to get into the
healthcare quality-improvement world. Its no surprise, since often times,
ICPs are the ones who actually are effecting change at their facilities.
Physicians will be involved, but it seems to me, the nurses are actually
spearheading the projects.

Bratzler concurs. The vast majority of surgeons are
ordering antibiotics, but we know they are not being given at the appropriate
time; weve seen operative teams take ownership of the fact they need to put
the systems into place, he says. Whether its the surgeon, or someone
else from the OR staff, somebody has to take the responsibility of ensuring that
the antibiotics get administered. In the infection control community, most
already have an ongoing program for surveillance for SSIs, and many of them are
doing things beyond what were looking at in the national project, other
things that reduce infection rates. ICPs have a key role in terms of their
ongoing surveillance.

The next phase of the national initiative, called the Surgical
Care Improvement Project (SCIP), is under development, according to Bratzler and
Houck. SCIP is a broad coalition of partners focused on improving surgical care
in the U.S. through the prevention of complications associated with

SCIP will take the measures we have been using for SIP,
which are entirely for antimicrobial prophylaxis, and expand them to address a
number of post-operative complications such as acute myocardial infarction or
post-op pneumonia, Houck says. Through SCIP, we will continue to work on
SSIs, but the scope of what were going to address will expand considerably.

Houck estimates that SCIP will be ready by the fall of 2005,
and currently, the group is working on establishing performance measures,
collecting data, and coordinating activities of all of the partners.

Whats so exciting about SCIP is the intense and intimate
participation by all the organizations, as well as the spread of the work
outside the Medicare population, Houck adds.

more information about the National Surgical Infection Prevention Project, go to